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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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  #1  
Old 01-11-2009, 04:30 PM
Sandra L Sandra L is offline
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Question Has anyone tried this?

Has anyone asked their insurance company if they would pay for the doctor, hospital, etc. and let you pay for the prosthesis? Wouldn't the costs be comparable to fusion? This would make ADR's more affordable and would let the insurance companies save MORE money. I also wonder why doctors don't have facilitators to help you with insurance, conscientious docs take the time others don't want to be bothered.

Just a thought, Sandy
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**Accidents, active life-style, always some back/neck pain controlled w/ibuphrofen
2004 excessive pain, x-ray, PT, MRI diagnosis cervical DDD
**PM recommended, meds, PT, massage therapy, chiropractor, injections
**Dec. 2007 numbness and weakness in left arm/thumb, x-rays, MRI, discs at C4-7 pushing on spinal cord, fusion or ADR out of country
**April 7, 2008, discogram at C3-4, surgery 4 levels, Prodisc-C, Dr. Bertagnoli, Germany
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  #2  
Old 01-11-2009, 07:44 PM
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Harrison Harrison is offline
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Exclamation Logical and intelligent idea, but...

Insurance companies work on another planet on these issues. I am straining my tiny brain to think of one or two patients that were successful in doing this. But it's always worth a shot to ask your provider(s)!
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
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  #3  
Old 01-11-2009, 10:19 PM
Nairek Nairek is offline
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Default

Quote:
Originally Posted by Sandra L View Post
Has anyone asked their insurance company if they would pay for the doctor, hospital, etc. and let you pay for the prosthesis? Wouldn't the costs be comparable to fusion? This would make ADR's more affordable and would let the insurance companies save MORE money. I also wonder why doctors don't have facilitators to help you with insurance, conscientious docs take the time others don't want to be bothered.

Just a thought, Sandy
Sandy,

When my husband had open enrollment with his health insurance, I contacted the companies that we had to choose from. Both said that I gave them billable codes but neither could say if they would pay for ADR surgery. When I asked if they would at least cover hospitalization, 1 company more or less said it's all or nothing.

My current OS has an awesome staff which includes a billing manager who is trying to help me to get my ADR surgery paid for. Many doctor's offices have people working there who can't be bothered with spending time helping patients get pre-certified. I had this problem with my previous OS & that was the reason why I went elsewhere.

In the end, fusion ends up costing more than ADR. But try explaining that to the insurance companies
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----Karin----
Disc Bulge C4/C5, Disc Degeneration T11/T12, Bi-Lateral tears L5/S1, Diagnosed w/ Lumbar Disc Derangement w/ Radiculopaphy. Treatment: IDET, Percutaneous Discectomy, SI Joint Injection, Facet Block. All failed. Empire BC/BS Denied Coverage for ADR-lost all of my appeals. MVP also denied coverage.

ALIF/PLIF Fusion 1/20/09
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  #4  
Old 01-12-2009, 01:13 AM
kimmers kimmers is offline
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Insurance companies are not logical.

Although ADR surgery might cost less than fusion surgery, in the short term and the long term, they do not care.
Yes, since I was having an ADR at L4/5 and it was basically almost the same surgery as an ALIF, you would think that if I paid for the ADR, they would pay for the surgery, but NO.

I hate to get on this soap box because it makes me so angry. I was basically told, (and this was from the head of grievances and appeals) that I could have a fusion and not an ADR surgery. Why not the ADR? Because there wasn't FIVE years of post-ADR approval studies on the ProDisc.

Well, I could not wait for five YEARS. I eventually got my ADR surgery but I went through postponements and it was just an incredible fight. I had help from my surgeon's office manager to do appeals. When we presented European and United States studies showing that ProDisc ADR was as good or better than fusion, I got a letter saying that only American studies would be accepted and that was a mute point because ProDisc was approved in 2006 and it was 2007 and that is not five years.

It went on and on.

I can tell you that you have to fight for the surgery and there are some people who didn't have to fight and were approved after one appeal. That is the fickle thing, they will approve one person and turn around and deny the next person. I would ask the insurance people, "How can you not approve me on the basis of there not being enough US long-term studies and then approve so and so??

I knew people in almost the same circumstances as me, same level, same DDD, who were approved.
When I asked, "Why they were approved?", I was told they could not discuss this with me because of HIPPA regulations and each patient's case "was decided on an individual basis."

People on here have suggested googling the insurance warrior because she has some good advice, I did contact her and that was helpful.

My best advice is that you don't take anything for granted and fight the insurance companies with everything you have. You have to be really serious and careful because the insurance companies will just expect you to roll over and follow their decision.

The sooner you push for everything on your first appeal, the better. I would call the insurance company everyday. I didn't do that and that was a mistake. I did call them several times and it was a pain-in-the-neck because it was difficult to get through each time. Also when I got my first denial, I didn't know to ask my surgeon to have a person-to-person conference call with the physican that denied the ADR.

They (the insurance companies) do not tell you what you can do to get approved, you have to find out by yourself and you have to document everything. (I am just speaking about the insurance companies who do not want to approve ADR.)

Good luck,

Kimmers
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  #5  
Old 01-12-2009, 10:37 AM
Sandra L Sandra L is offline
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Join Date: Jan 2008
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Default Legislation and a Class-Action Suit - Cover FDA Approved Surgery

Maybe we should try the legislative route. Course we could all be dead before we were successful!

Writing letters to your senators/congressmen does help IF it's done on a huge scale. I am involved in a class-action lawsuit that started with trying to get legislation changed. We gave people "sample" letters that they could "change" to fit their situation. Most people don't feel comfortable writing letters, so giving them an example helped. We did the same with emails and flooded their mailboxes, ditto phone calls. Posted their email addresses and government mail addresses and phone numbers. Got their attention, but not legislative changes .

This lead to a class-action lawsuit, but it takes years.

None of this works unless you have people to organize the effort and make it a nationwide project. The environmental groups are very good at this. There should be a medical activist group! Large groups making loud noises works best. All sounds good, but not easily accomplished.

Talk is easy , but putting time, effort and money where your "mouth is" is huge job. Been there, still doing it .

Sandy
__________________
**Accidents, active life-style, always some back/neck pain controlled w/ibuphrofen
2004 excessive pain, x-ray, PT, MRI diagnosis cervical DDD
**PM recommended, meds, PT, massage therapy, chiropractor, injections
**Dec. 2007 numbness and weakness in left arm/thumb, x-rays, MRI, discs at C4-7 pushing on spinal cord, fusion or ADR out of country
**April 7, 2008, discogram at C3-4, surgery 4 levels, Prodisc-C, Dr. Bertagnoli, Germany
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